A Good Night’s Sleep

You may have discovered as you travel this weary road of life that you’re not sleeping quite as well as you did as when you were younger. Gone are the glory days when you fell asleep listening to a bedtime story and then, suddenly, it’s morning! What happened? “Why,” you ask (and probably too often), “am I lying here in the dark waiting to get back to sleep? I know I’m going to be exhausted in the morning.”

Actually, despite your worries, you’ll probably be less tired than you fear. You’ve fallen for that old myth about needing eight hours of uninterrupted sleep. Last week’s Sunday New York Times summarized what sleep specialists have known for the past few years: that the human animal was never really intended to sleep steadily through an eight-hour block of time. Children, yes–eight, ten hours. But for adults, nearly half of us (myself certainly included) find it virtually impossible to experience this type of uninterrupted sleep regularly.

Just 40% of us clamber into bed, are asleep within a half hour or so, and awaken refreshed the next morning. Our sleep abilities, by the way, steadily decline with age. Sixty-year-olds have more trouble than 40-somethings, who in turn sleep poorly when compared to teenagers. Another 40% of us sleep erratically, waking in the middle of the night, moaning as we glance over and see 2:30 AM or thereabouts on the clock. Once this was called being “sleep deprived,” but researchers have had second thoughts given that the allegedly deprived sleepers were often quite energetic and functioning well the following day…if they were able to get back to sleep in an hour or so.

This pattern of dividing sleep into two phases is called Sleep #1 and Sleep #2. For Sleep #1, you’re able to fall asleep fairly promptly and you actually sleep quite efficiently, but then you find yourself awake in the middle of the night. At this point, you can go down one of two paths. In the first, you lie awake worrying about getting back to sleep, agonizing over how tired you’ll be later in the day, bitter that it’s now too late to take a sleeping pill. On the second path you’re more accepting of the situation. You use the waking time to read for awhile, mull over something pleasant, or listen to some relaxing music until you sense you’re getting sleepy enough to go back to sleep. You then enter Sleep #2, a phase not as deep as the first, but if you can manage three or four hours you’ll do just fine the next day.

The remaining 20% probably need sleep medications

People endlessly worry about sleep meds. In fact, many people worry so much that the worrying alone keeps them from getting to sleep. Are sleeping pills addictive? No, and you won’t go through withdrawal if you stop them suddenly. No 7-11 has ever been robbed by an addict seeking money for his Ambien. But are they habit forming? The other term for habit forming is “psychological dependence” and the answer is yes, they are habit forming. For example, if you’ve been using Ambien and you run out of pills, you’re likely to worry that your need for sleep won’t be fulfilled. If you stay off the Ambien you’ll experience a few days of what’s called rebound insomnia as your brain queries, “Hey, pal, where’s my Ambien?” before returning to your old sleep-deprived self.

We can be psychologically dependent on a lot of things that aren’t dangerous: coffee in the morning, a cocktail before dinner, jogging. Are you seeing the difference here between crystal meth and Ambien? I’m trying to help you over your fears.

There are two groups of medication-needing insomniacs:

• Group one  A lot of people, no matter how exhausted they are at bedtime, simply cannot fall asleep regularly. Most in this group can differentiate between a night when they’ll “probably” fall asleep on their own from a night when they’re certain sleep will elude them. For you in this group, I recommend having a sleep medicine (called a hypnotic) available. There is no more self-fulfilling a prophecy than lying in the darkness wondering if you’re going to fall asleep. Just take the Ambien (or Lunesta, trazodone, or whatever works), turn out the light, and go to sleep. Feeling guilty won’t help you relax.
• Group two  People in this group fall asleep quite easily but then snap awake in the middle of the night and, instead of returning to Sleep #2, simply can’t get back to sleep. You’ve tried all the back-to-sleep tips without success. Now you’re awake and dawn is three or four hours away. You agonize over how sluggish you’ll be at work. For you, two medications are available that many patients don’t know exist, Sonata and Intermezzo. When Sonata (zaleplon) was introduced years ago, it was a flop because patients were taking it at bedtime and then waking up refreshed at 2 AM. Years later, it was recognized that Sonata’s short sleep effect was ideal for people who awoke as late as 3 AM, because the drug is virtually out of your body by 6:30 or 7:00 AM. Unfortunately, it was too late for the manufacturer to get FDA approval for “middle of night awakening” and Sonata quietly went generic (100 capsules cost about $50.00). Intermezzo is a newly released form of Ambien available in a much smaller dose (3.5 mg instead of the usual 10 mg) as an instantly dissolving lozenge, melting in your mouth and putting you to sleep within minutes. Intermezzo is definitely not generic but is covered by most health insurers.

We know that people who sleep enough so they’re not tired the next day do feel better and overall are healthier. It’s not so much the number of hours you’re sleeping, but how you feel the day after. Some people need six hours, some seven, some nine. And even though an average number for humans might be seven, those who feel great with six should leave well enough alone.

People who don’t get enough sleep feel dull and tired the next day. Ideally, they should be allowed daytime naps, but virtually no employer permits this luxury (except for Google, which encourages napping). If you feel dull and tired after a wakeful night, analyze your sleep pattern. If you simply can’t fall asleep, start by trying supplements like tryptophan, valerian, or melatonin. Work with a sleep-inducing CD and also review my list of suggestions for better sleep. If you get nowhere with these, ask your doctor for a sleeping pill.

If you’re in the second group, waking in the middle of the night, try reading some poetry or visualizing an especially nice vacation until you drift back to sleep. If you’re stuck and can’t get back to sleep, ask your doctor for a Sonata or Intermezzo. Life’s too short to feel guilty about taking a sleeping pill.

Be well,

David Edelberg, MD